The Wire Twisting/Locking Technique to Facilitate Precise PDA Stent Delivery in Neonates with Ductal-Dependent Pulmonary Blood Flow

Fig. 1.. 3D reconstruction from CT scan showing a posterior view of the aorta (red), pulmonary arteries (blue), and the PDA (green). The orange cylinder represents the trajectory from the left axillary artery to the PDA orifice, while the gray cylinder represents the trajectory from the right axillary artery. Notably, although the left axillary/left subclavian artery is anatomically closer to the PDA, the trajectory from the right common carotid artery aligns more directly with the PDA. The thin orange line illustrates the length of the PDA from the aortic to the pulmonary end if fully straightened, highlighting that the actual PDA length is much longer when accounting for its natural tortuosity. LSC left subclavian artery, LCC left common carotid artery, RCC right common carotid artery

Fig. 2. Demonstrates Umbilical access for PDA stenting; a–d Sequential fluoroscopic images illustrating the advancement of the stent through a tortuous downward and upward trajectory through the umbilical artery into the iliac artery. Note that two forceps were used on either side of the umbilical stump to pull it up, facilitating the stent's progression through the long sheath along the tortuous course

Fig. 3. a Aortogram in the anteroposterior projection showing a PDA originating from the innominate artery, with stenosis at the pulmonary end of the PDA and the proximal right and left pulmonary arteries. b, c A 4 F-long sheath is positioned in the aorta at the aortic end of the PDA, with a BMW wire anchored in the distal LPA. Note the soft wire becomes straighter when pulled, increasing stiffness. d, e A long PDA stent is advanced over the BMW wire, with varying wire tension to navigate the curve effectively. f Post-deployment angiogram in the aorta shows the PDA stent securely positioned with minimal repositioning as the wire is withdrawn. The microcatheter remains in place (the arrow indicates the microcatheter tip)

Fig. 4. a A 4 F short sheath is placed in the right carotid artery. A microcatheter and BMW wire are advanced across the PDA, demonstrating the wire's ability to conform to the ductal anatomy without causing tension or spasms. b The wire twisting/locking technique is employed to increase the wire’s stiffness, enabling controlled navigation and precise stent positioning. c A second stent is deployed through the first stent to ensure complete coverage of the aortic end. Adjusting the wire tension (pulling it while its distal end is locked) allows the centering of the second stent through the first stent. d Final angiographic confirmation shows appropriate stent placement with adequate aortic and pulmonary ends coverage